Rehabil itationAfter HipFemoroacetabularImpingementArthroscopy

Michael Wahoff, PT, SCS*, Mark Ryan, MS, ATC, CSCS

KEYWORDS

� Rehabilitation � Circumduction� Femoroacetabular impingement � Return to sport

More than 30,000 hip arthroscopies were performed in 2008. This number is expectedto grow at a rate of 15% over the next 5 years, resulting in more then 70,000 hiparthroscopies performed each year by 2013.1 Hip arthroscopic techniques to repairlabral tears and address femoroacetabular impingement (FAI) continue to evolve.Multiple published studies have reported positive surgical outcomes.2–8 Althoughthere is evidence to support arthroscopic procedures to address labral tears andFAI, there are few published evidence-based rehabilitation studies dedicated to post-operative rehabilitative care.9–11

Pain, loss of motion, changes in muscle strength and motor control, loss of stability,and loss of function can be caused by FAI and labral tear.12–14 Hip arthroscopic proce-dures are used to correct the bony geometry and provide an intact labral complex andligamentous structure for improved hip congruency. A thorough postoperative rehabil-itation program must protect the integrity of these healing tissues, control pain andinflammation, allow for early range of motion (ROM), reduce muscle inhibition, restoreneuromuscular control and proprioception, normalize gait, and improve strength. Forthe athlete, power, speed, and agility are recommended for optimal return to compe-tition. A positive outcome is not necessarily how quickly patients return to theirpreinjury level of function or sport but the overall longevity and patient satisfaction.

PRINCIPLES OF HIP ARTHROSCOPY REHABILITATION

The following are the key principles of rehabilitation after hip arthroscopy: (1) rehabil-itation is an individualized and evaluation-based (not time-based) program designed

The authors have no conflicts of interest.Howard Head Sports Medicine, 181 West Meadow Drive, Vail, CO 81657, USA* Corresponding author.E-mail address: Wahoff@vvmc.com

Clin Sports Med 30 (2011) 463–482doi:10.1016/j.csm.2011.01.001 sportsmed.theclinics.com0278-5919/11/$ – see front matter � 2011 Elsevier Inc. All rights reserved.

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to be able to address specific findings of the surgeon, the procedures performed, andthe patient’s individual characteristics; (2) circumduction is critical for early mobility toprovide an environment in and around the joint to reduce the risk of scar tissue; and (3)sport-specific functional rehabilitation should be provided.Rehabilitation is considered individualized, with specific time lines for weight

bearing and ROM restrictions determined by the specific procedures performed onthe patient. Compliance with these restrictions by patients and therapists is criticalto allow for soft tissue healing. Rehabilitation is done in phases and should be compre-hensive, be easy to understand, and err on the side of safety. Exercise progressionsused are similar in all patients during the early and mid phases. Specific objectivecriteria to advance are used to progress to the next phases. Such advancement allowsfor differences in a patient’s age, genetics, nutrition, concomitant injuries, symptomonset, goals, and sport-specific demands.15 The 4 phases of rehabilitation includemaximum protection and mobility (phase 1), controlled stability (phase 2), strength-ening (phase 3), and return to sport (phase 4) (Fig. 1).

REHABILITATION PROTOCOLS

Phase 1 of the rehabilitation program is shown in Table 1. Hip arthroscopy isa package of several to all procedures listed in Table 2. Patients who undergo amicro-fracture for the treatment of full-thickness chondral injuries are restricted to foot-flatweight bearing (FFWB, 9 kg) for 6 to 8 weeks.2,16 Patients who do not undergo amicro-fracture are restricted to FFWB for 3 weeks to decrease postoperative inflammationand reduce the risk of a stress fracture due to the osteoplasty. Patients are restrictedto 50% weight bearing for another week to allow time for restoration of motor control.Hip extension past neutral is restricted for 21 days because it has been shown toincrease anterior hip forces and place stress on the anterior labrum and capsule.17

ROM restrictions also include no external rotation (ER) for 17 to 21 days, dependingon the viability of the tissue, capsular closure technique, and overall joint laxity; flexionup to 120�; and abduction up to 45�. A hip hinge brace assists in limiting extension andER and is worn when ambulating for 17 to 21 days. Patients wear calf pumps while atrest as a preventative measure for blood clots.

Fig. 1. The 4 phases of rehabilitation as shown in a motor control diagram.

Table 1Phase 1 of rehabilitation program

Phase 1: Maximum Protection and Mobility

Goals 1. Protect the integrity of the repaired tissues2. Diminish pain and inflammation3. Restore ROM within the restrictions4. Prevent muscular inhibition

Restrictions See Table 2

Treatment Strategies 1. CPM: 30�–70� placed in 10� abduction4–6 h/d � 3 d, then 1–2 h/d � 2 wk (non-Mfx patients)4–6 h/d � 6–8 wk (Mfx patients)16

2. Ice and compression: as needed in phase 13. Nonresistant stationary bicycle: 20 min 1–2 times/d � 6 wk4. Circumduction (passive ROM): 2 times/d � 2 wk,

then daily through 10 wk5. Laying prone for a minimum of 2 h/d: phases 1 and 26. Lymphatic massage/soft tissue: as needed in phases 1 and 27. Pain-free gentle muscle stretching8. Isometrics9. Active ROM: emphasis on gluteus medius and deep rotators

10. Aquatic pool program11. Cardiovascular and upper body exercises (see Table 5)

Minimum Criteria ToAdvance

1. Minimal complaints of pain with all phase 1 exercises2. Proper muscle firing pattern with all phase 1 exercises3. Minimal complaints of “pinching” sensation in the

hip before 100� of flexion4. Full weight bearing is allowed and tolerated

Abbreviations: CPM, continuous passive motion; Mfx, microfracture.

Table 2Restrictions and precautions per surgical procedures performed

Procedure PROM WB CPM Brace

Osteoplasty RimTrimming

No limits FFWB � 21 d then50% � 1 wk

4–6 h � 3 d then1–2 h � 2 wk

21 d

Chondroplasty No limits WBAT 4–6 h � 3 d then1–2 h � 2 wk

No

Microfracture No limits FFWB � 6–8 wk 4–6 h � 6–8 wk No

Labral Repair Flexion up to 120�,abduction up to 45�

No external rotation� 17–21 d,Ext to 0 � 1 wk butno ext > 0 x 17–21 d

— 4–6 h � 3 d then1–2 h � 2 wk

17–21 d

Capsule Plicationand CapsuleClosure

Flexion up to 120�,abduction up to 45�

No external rotationfor 17–21 d, Ext to0 � 1 wk butno ext >0 x 17–21 d

— 4–6 h � 3 d then1–2 h � 2 wk

17–21 d

Abbreviations: CPM, continuous passive motion; FFWB, foot-flat weight bearing; PROM, passiverange of motion; WB, weight bearing; WBAT, weight bearing as tolerated.

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POSTOPERATIVE THERAPY MODALITIES

Pain and inflammation is decreased with ice, compression, and lymphatic massage.As the initial swelling decreases, other soft tissue techniques are used, includingeffleurage, petrissage, myofascial release, and active release techniques. Emphasisis placed on the tensor fasciae latae (TFL), gluteus medius, iliotibial band, adductors,iliopsoas, and lumbar spine.Mobility within the ROM restrictions is achieved with the continuous passive motion

machine, stationary bike, aquatic therapy, and passive ROM, with emphasis on cir-cumduction (Fig. 2). Patients are instructed to lay prone for a minimum of 2 h/d tokeep the hip flexors from shortening.

MUSCULATURE RESTORATION

Restoration of normal muscle performance is critical to reestablish dynamic hip jointcongruency after surgery. Correct motor function is achieved through careful selectionof exercises for muscular strength (capacity to actively develop tension), work (force�distance), power (rate of work output), or endurance (ability to delay onset of fatigue).18

Isometric (static), isotonic (eccentric or concentric), slow- and fast-speed dynamic,and functional exercises are used depending on the phase of rehabilitation and thegoal of the exercise. Goals of these exercises can include preventing muscle inhibi-tion, regaining neuromuscular control and proprioception, or increasing strength,power, and/or endurance. It is critical that the exercises selected are based notonly on the muscles recruited and the amount of force they will produce but also onthe fact that they can be performed while maintaining the surgical precautions andwith consideration to the joint reaction forces that they may place on the joint.Quadriceps, gluteus maximus, and transverse abdominis (TA) pain-free isometrics

are initiated on day 1. Active prone hamstring curls are used to facilitate early motorcontrol, active prone terminal knee extensions (Fig. 3) are used to facilitate glutesand quads to neutral hip extension, and active prone and hook-lying internal rotations(Fig. 4) are used to facilitate active rotation within safe ROM. Quad rocking facilitatespatient-controlled hip flexion and can be used to facilitate spine mobility or stability.Stool rotations (Fig. 5) are used after week 3.

It has been shown that the gluteus medius muscle is a key stabilizer of the hipduring gait.19 Gluteus medius strength when compared with the maximum voluntarycontraction from the smallest amount of force produced to the highest is achievedwith supine abduction, non–weight-bearing standing abduction, side-lying abduction,

Fig. 2. Circumduction. (A) Passive clockwise and counter-clockwise ROM at the hip at w70degrees flexion. (B) Passive clockwise and counter-clockwise ROM at the hip with the legstraight.

Fig. 3. Prone terminal knee extensions. (A) Start position. (B) Extend knee and hip to neutralwith quad and glutes.

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weight-bearing opposite hip abduction, flexed hip weight bearing opposite hip abduc-tion, and pelvic drop exercises, respectively.20 This progression to strengthen thegluteus medius is used with the exception of side-lying abduction, which should beavoided because of the increased acetabular joint forces.21 Standing abduction ininternal rotation (Fig. 6) is emphasized throughout rehabilitation because it can be per-formed early to activate the gluteus medius within the ER restrictions and because ofthe low flexor activation with this exercise.Gentle stretching of the iliopsoas is performed early by bringing the patient’s oppo-

site knee to the chest in supine position. Gentle Thomas stretch can be used whentolerated after week 4 and kneeling stretch when the patient can tolerate weightbearing. Patient can gently stretch the quads and hamstrings when pain free. Thepiriformis can be stretched in side-lying position with support. Stretching of theadductors is not recommended to protect the surgical area; however, soft tissuework seems to reduce the patient’s complaint of tightness usually brought on byhypertonicity in this muscle group. Aquatic therapy is highly recommended throughoutrehabilitation. Protection of the incisions is achieved with op-site waterproof dressings(Smith and Nephew, London, UK).Daily circumduction is continued, whereas ER and extension are initiated by the

physician’s orders. Active assisted FABER slides (Fig. 7) and active butterfly exercise(Fig. 8) allow the patient to control the amount of ER.

REHABILITATION PROGRESSION

Weaning off crutches depends on the patient’s tolerance to the gradual increase inweight bearing and demonstration of proper firing of the gluteal muscles without

Fig. 4. Active reverse butterflies. (A) Start in hook-lying position with feet slightly widerthan shoulder width apart and toes pointed inward. (B) Rotate thighs inward to touch kneesand hold 5 seconds then bring knees outward.

Fig. 7. FABER slides. (A) Start position with heel resting on hand which is resting on tableand opposite hand behind knee. (B) Active assisted flexion, abduction, and external rotationsupporting and assisting as needed.

Fig. 5. Stool rotations. (A) Knee flexed to 90 degrees placed on spinning stool and lightlyweighted with hip in neutral. (B) Actively rotate hip inward controlling pelvis with coremuscles then return to neutral. (C) When external rotation allowed, actively rotate hipoutward.

Fig. 6. Standing abduction in internal rotations. (A) Start position with knee straight andtoes pointed slightly inward. (B) Slowly bring your leg straight out to the side keepingtoes slightly pointed inward and your pelvis level.

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Fig. 8. Active butterflies. (A) Start position hook-lying with feet shoulder width apart. (B)Slowly allow knees to fall out and hold 5 seconds then return.

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a Trendelenburg gait (phase 2 as listed in Table 3). Progressive increases in weightbearing of 10% to 25% every 1 to 3 days or slower is recommended. Aquatic therapymay assist in the patient’s ability to wean off crutches. Restoring normal gait withoutusing a standard or underwater treadmill is recommended because the authors thinkthat a sheer stress is placed on the anterior aspect of the hip when ambulating on themoving tread of the treadmill.

Table 3Phase 2 of the rehabilitation program

Phase 2: Controlled Stability

Goals 1. Normalize gait2. Restore full ROM3. Improve neuromuscular control, balance, proprioception4. Initiate functional exercises maintaining

core and pelvic stability

Precautions 1. Recommend no treadmill use2. Avoid hip flexor and adductor irritation3. Avoid joint irritation: too much volume,

force, or not enough rest4. Avoid ballistic or aggressive stretching

Treatment Strategies 1. Wean off crutches as per weight-bearing guidelines2. Gait training with emphasis on gluteal

firing and core control3. Nonresistant stationary bicycle until a minimum of 6 wk4. Circumduction, prone lying, and soft tissue and muscle

stretching as before5. Full passive ROM including ER and extension6. Active ROM, core stability, weight bearing, and movement

preparation exercises7. Progress aquatic pool program8. Progress cardiovascular and upper

body exercises (see Table 4)9. Initiate functional exercises in late phase 2

Minimum Criteria toAdvance

1. Gait is pain free and normalized2. Full ROM with mild stiffness into ER3. No joint inflammation, muscular irritation, or pain4. Successfully initiated functional exercises without pain and

good neuromuscular control

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MUSCULATURE BALANCE

Assessment of the entire lumbar-pelvic-hip complex and lower extremity kinetic chainhelps to address muscle imbalances, sacroiliac joint, lumbar spine articular dysfunc-tions, and restrictions in the fascial planes. Treatments to facilitate normal mechanicsof these functional units include manual mobilization and/or manipulations of thethoracic or lumbar spine, sacroiliac joint, and soft tissue work as previouslydescribed.22–25 Manual mobilization of the hip capsule is performed only as neededafter week 6.During this phase, improvement of neuromuscular control is critical using sensori-

motor exercises for balance and proprioception. Endurance is emphasized while usingweight-shifting exercises including reverse lunge static holds (Fig. 9) and double kneebends with weight shift. Standing abduction in internal rotation (SAIR) is performedbilaterally, and exercises emphasizing the gluteus maximus and medius, includingprone hip extensions off the edge of tables, bridges, and clams, and manually resistedexercises are performed. Core exercises such as supine heel slides, supine marching,or standing knee to chest are used to facilitate the iliopsoas muscle. These exercisesshould be performed with proper firing of the TA in core neutral position while avoidingoverfiring of the TFL. Emphasis is placed on correct muscle firing patterns while notallowing patients to work beyond their ability. A dynamic movement preparation groupof exercises including toe touches, standing knee to chest (Fig. 10), standing knee tochest with rotation (Fig. 11), walk outs (Fig. 12), lateral lunges, and scorpions (Fig. 13)can be initiated. Pilates as an adjunct to rehabilitation is recommended versus yoga.

Fig. 9. Reverse lunge static hold. Start with surgical leg forward with hip and knee flexedand opposite leg straight behind. Slowly shift your weight onto the forward leg by comingup on the toes of the back foot while bending at the ankle of the forward foot.

Fig. 10. Standing knee to chest.

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REHABILITATION: MIND AND BODY

Rehabilitation after hip arthroscopy can be a challenge for many patients who areotherwise very active individuals. The long period of inactivity after surgical proce-dures can be difficult on the athlete/patient both mentally and physically. There aremany options available for athletes that concurrently address the rehabilitation ofthe hip while maintaining or minimizing the loss of fitness. These activities can beperformed in compliance with all weight-bearing and ROM restrictions. Incorporatinga philosophy of focusing not only on the surgically repaired hip and each phaseindividually (as seen in Fig. 14) but also on the athlete or patient as a whole (asseen in Fig. 15) keeps the athletes engaged mentally and physically and should allowfor an easier transition to their respective sport when the injured hip is healed. Athletescan take pride in maintaining fitness or even improving on weaknesses that otherwisego unaddressed in their sport training (Table 4).

ADVANCING REHABILITATION BEYOND THE HIP

Cardiovascular fitness activities are generally started during phase 1 after postopera-tive day 7. Intensity and duration can be progressed throughout phase 1 and cancontinue into phase 2 of the hip rehabilitation program.Upper extremity strengthening is efficiently, effectively, and safely performed during

phase 1 using suspension-type training. This setup allows the patient to performa multitude of exercises using body weight resistance rather than attempt to carry

Fig. 12. Walk out. (A) Start in standing then bend forward and touch the floor keeping theknees straight and walk the hands out. (B) Keeping the knees straight and hands in one spotwhile walking the feet up. (C) Walk hands out again.

Fig. 11. Standing knee to chest with rotation.

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Fig. 13. Scorpions. (A) Start position on stomach with arms straight out in a T. (B) Keepingthe shoulders as flat to the floor as possible bring the leg and hip up and across the oppositeleg rotating from the hip, pelvis, and spine. (C) Return and perform with the opposite leg.

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dumbbells or other weights while on crutches. Minimal movement is required, andresistance can easily be altered with small changes in foot position. Bodyweightcan be distributed as dictated by weight-bearing restrictions. Cord resistance exer-cises can be used in late phase 1, whereas sitting on a Swiss ball and/or kneelingfor proprioceptive training as the patient is weaning off crutches (Fig. 16).During the later stages of phase 2, nonmicrofracture patients may be cleared to

begin running in the pool in chest-deep water progressing to waist-deep water. Thisexercise is done in preparation for the land running progression at the beginning ofphase 3. Running is delayed as long as possible for patients who have undergonea microfracture, but pool running should be initiated several weeks in advance ofland running if necessary for the running athlete. Skating athletes are allowed to returnto the ice at this time. Cycling resistance can be added at week 6.Phase 2 sees more mobility of the patient and allows a return to the athlete’s presur-

gery upper extremity strength regimen. Returning to the gymnasium to use dumbbells,barbells, and/or machines, athletes can achieve previous levels of upper bodystrength. Core conditioning can be advanced as well, with consideration to typeand intensity of forces placed on the hip with particular attention to iliopsoas overuse.The athletes are allowed to initiate their sport progressions during phase 3, provided

they have restored a normal gait and established the necessary strength and stabilityaround the hip joint. This initiation will allow athletes to load the entire system (heart,lungs, muscles, joints) similar to the loading requirements of their sport to maximize

Fig. 14. Rehabilitation as separate phases.

Fig. 15. Rehabilitation as a continuum.

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motor control and metabolic demands as the overall strength of the hip increases.Following the 3 P’s principle, the program is pain-free, progressive, and predictable.

RETURN TO PLAY

Sport progressions during this stage are performed within a pain-free ROM, witha duration and intensity that does not result in an increase in soreness of the joint ormusculature. A progressive plan involves beginning with simple, slow, and short-duration activities. As the athlete gains strength, endurance, and confidence in thehip, more complex and faster movements of increasing volume can be performed.A predictable plan means beginning only with movements that are known to theathlete. It is not a time to explore a new running, cycling, or skating form or a routethat may have unknown distances or uneven surfaces or require reactive movementssuch as defending someone.Running progression on land and skating progressions with specific drills and

speeds are initiated. The athlete can now swim without the pull buoy, and cyclingresistance can be further added. Athletes are allowed to shoot a basketball, throw

Table 4Cardiovascular fitness and conditioning

Cardiovascular Fitness Upper Body/Sport Specific Conditioning

Phase 1 55%–70% of maximum heart rateup to 30 min

1. Upper body ergometry2. Single well–leg rowing3. Swimming with pull buoy

1. Suspension-type training (see Fig. 16)2. Cord resistance exercise training

Phase 2 85% for phase 1 cardiovascularexercises; 55%–70% for phase 2exercises

1. Swimming with pull buoy2. Easy return to ice for skating

sports3. Resistance on bicycle

1. Presurgery upper body regimen:dumbbells, barbells, machinesat lower resistance

2. Core conditioning: planks,crunches, avoiding hip flexordominant exercises

Phase 3 1. Swimming without pull buoy2. Running progression in pool

(non-Mfx patients)3. Running, skating, cycling

progressions4. Strength days emphasizing PAQ

with minimum rest between setsin late phase 3

1. Shooting, swinging, hitting,dribbling, kicking, throwingsport–specific progressions

Phase 4 1. Maximize presurgery fitnessregimen: running, cycling,skating, swimming,strengthening

1. Advanced sport specific drills

Abbreviations: Mfx, microfracture; PAQ, power, agility, quickness.

Fig. 16. TRX Suspension Training (Fitness Anywhere, Inc, San Francisco, California). (A & B)Push start-end. (C & D) Pull start-end.

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a baseball, swing a racquet or a bat, or dribble or pass a soccer ball depending on theirindividual sport. The volumes and intensities at which these sport-specific exercisesare performed need to be to be controlled, and rest days are mandatory. A carefulplan is best developed to find a balance in strengthening; cardiovascular, aquatic,core, and sport-specific exercises; and rest.

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Sport progressions, as previously described, are critical aspects of phases 3 and 4,whereas double leg strengthening is initiated and progressed to single leg strength-ening. Phase 3 is shown in Table 5. Neuromuscular control emphasized in phase 2is maintained. Endurance strength is emphasized (15–20 repetitions minimum)throughout phase 3, eventually incorporating power, agility, and quickness traininginto the program. Depending on the demands of the sport involved and the overallcondition of the surgical hip, the athlete’s strengthening program is adjusted withfocus primarily on progressive endurance strengthening, power and agility move-ments, or both. Cardiovascular fitness is achieved with the traditional programs(running, bike, elliptical trainer), sport progressions (skating, dance), or metabolicconditioning that is gained from using power and agility exercises with shorter restperiods. Recovery during this training can include balance, coordination, or mobilityexercises.Passive circumduction is continued for 10 weeks and should continue actively for an

additional 4 weeks; soft tissue work and gentle stretching should also be done. Gluteactivation exercises continue using SAIRs, single leg bridges, and manually resistedexercises. Core neutral position with transverse abdominal control should be empha-sized with all exercises.Double leg strengthening includes leg press, double knee bends with resistance,

and tuck squats (Fig. 17). Olympic lifts are not recommended early because of thequick explosive movements required to perform them correctly. Single leg strength-ening progressively added includes balance squats (Fig. 18), split squats (Fig. 19),reverse lunges, lateral lunges (Fig. 20), and single knee bends (Fig. 21). Resistanceis added with sport cords, dumbbells, or kettlebells. As the patient demonstratesthe ability to perform single knee strengthening with adequate endurance and goodform, power and agility movements are added, including lateral and diagonal agilitieswith sport cords. Single knee bend, lateral agility (Fig. 22), diagonal agility (Fig. 23),

Table 5Phase 3 of the rehabilitation program

Phase 3: Strengthening

Goals 1. Restore muscular strength and endurance2. Optimized neuromuscular control, balance, proprioception3. Restore cardiovascular endurance4. Progress sport progressions

Precautions 1. Recommend no treadmill use2. Avoid hip flexor and adductor irritation3. Avoid joint irritation: too much volume, force, or not enough rest4. Avoid ballistic or aggressive stretching5. Avoid contact and high velocity activities

TreatmentStrategies

1. Continue circumduction, prone lying, soft tissue, muscle stretching,gluteal activation, core stabilization, movement prep exercises andaquatic pool program as needed

2. Sport progressions or functional activities3. Cardiovascular fitness (see Table 4)4. Double leg strengthening5. Single leg strengthening

MinimumCriteria toAdvance

1. Perform all phase 3 exercises pain free and with correct form2. Pass sport test

Fig. 17. Tuck squats.

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and forward lunge onto a box (Fig. 24) are the 4 exercises that comprise the sporttest.10

Phase 3 should culminate in the passing of a sports test (as shown in Table 6) thatonce completed allows the athlete to return to practice without limitations to train andprepare for competition. The athlete transitions into full training with a dedicated returnto sport plan with any specific precautions as recommended by the physician.Specific demands of the sport are addressed with advanced power, plyometrics,performance, and conditioning training. These transitions should occur smoothlynot only if hip-specific treatments were applied throughout the phases of rehabilitation

Fig. 18. Balance squat. (A) Start position with one leg behind supported on a bench andother leg forward enough to prevent knee from coming out past the toes when squatting.(B) Perform squat on forward leg keeping pelvis level.

Fig. 20. Lateral lunge. (A) Start position. (B) Step lateral while squatting keeping the kneestraight ahead and the pelvis level.

Fig. 19. Split squat. (A) Start position with one leg behind on the floor while other leg isforward enough to prevent knee from coming out past the toes when squatting. (B)Perform squat on forward leg keeping pelvis level.

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Fig. 22. Lateral agility. (A) Start position: Sport cord attached from the wall to the waist.First line placed on floor the distance away from wall where the cord remains taut. Secondline is the placed away from the first the distance from the patient’s greater trochanter tothe floor. (B) Patient performs a lateral push-off from the leg nearest the wall with enoughforce to land with the opposite leg past the second line. (C) The increase in cord tension willresult in a force that pulls the patient back. The patient should land in front of the first lineand absorb the landing with a controlled squat.

Fig. 21. Single knee bend. (A) Start position. (B) Keep knee from collapsing into adduction,internal rotation and valgus and hip neutral while performing single leg squat 30–70degrees knee flexion.

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Fig. 24. Forward lunge onto box. (A) Start position. Cord attached from wall to back ofwaist and taut. (B) Perform a deep forward lunge onto a box the height of the patient’sknees then return and perform with opposite leg.

Table 6Functional hip sport test

Exercise Goal Points

Single knee bends 3 min 1 point earned for each 30 s completed

Lateral agility 100 s 1 point earned for each 20 s completed

Diagonal agility 100 s 1 point earned for each 20 s completed

Forward lunge on box 2 min 1 point earned for each 30 s completed

Passing score: 17 of 20.

Fig. 23. Diagonal agility. (A) Start position: Same as lateral agility except 2 lines are placedat a 45 degree angles forward and backward from the first. (B) The patient performs thelateral push-off from the leg nearest the wall as before but lands first rep on forwardline. (C) The patient returns to the first line landing in a controlled squat. (D) The patientperforms the next rep landing on the back line and continues alternating forward andbackward lines.

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Table 7Phase 4 of the rehabilitation program

Phase 4: Return to Sport

Goals 1. Restore power and maximize plyometric strength2. Return to play3. Independent in maintenance program4. Understands proper care for the long-term health of the hip

Precautions 1. No specific precautions unless noted by the physician

Treatment Strategies 1. Develop a return to sport plan2. Sport training and conditioning3. Power, plyometric, performance training

Minimum Criteria toAdvance

1. Cleared by the physician2. Completed sport training and conditioning3. Full return to nonrestricted practice

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but also if cardiovascular fitness, conditioning, and sport progressions were used.Phase 4 is shown in Table 7.

SUMMARY

Rehabilitation after FAI arthroscopy is different for different patients. By following therestrictions set by the physician while performing early circumduction, using theminimal criteria to advance through each subsequent phase, and allowing patientsto perform functional sport progressions throughout the rehabilitation athletes willbe able to return to sport smoothly and effectively with positive outcomes.

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